Miss Clark heard her daughter coughing at 10.30pm and called an ambulance after finding her struggling to breathe, with her hands and face blue.

The little girl died shortly after arriving at the Royal Gwent Hospital.

An inquest into Ellie-May’s death at Newport Coroner’s Court heard Dr Rowe had previously received a letter from a consultant stating that the little girl was at risk of having “an episode of severe/life threatening asthma”.

Dr Rowe did not ask the reason behind Ellie-May’s emergency appointment, or look into her medical notes before refusing to see her.

An inquest heard Doctor Joanne Rowe had a strict policy over lateness and did not review the five-year-old’s notes

Returning a narrative verdict, coroner Wendy James ruled said ‘unacceptable’ chances had been missed to save Ellie-May.

She said: “From the evidence before me, it is not possible for me to determine with certainty whether an earlier intervention would have altered the outcome for Ellie but nonetheless Ellie should have been seen by a GP that day and she was let down by the failures in the system.

“Ellie-May Clark died of natural causes where the opportunity to provide potentially life-saving treatment was missed.”

Speaking after the verdict, Ellie May’s family said they were disappointed a neglect ruling had not been reached and blamed the doctor for her death.

Ellie-May was turned away from The Grange Clinic in Newport, south Wales

She heard Ellie-May coughing at 10.30pm and went into her bedroom to give her an inhaler.

“She fell off her bed onto the floor,” Miss Clark said. “I turned her light on and I saw her hands and her face were blue. I rang 999 straight away.”

The inquest heard Dr Rowe could have asked another doctor to see Ellie-May, could have seen her after her patient had left and could have spoken to the doctor who arranged the emergency appointment for her.

When asked why she had not, Dr Rowe replied: “I don’t know. I was busy seeing to the other patient that I had with me.”

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She confirmed she would have acted differently if she had seen Ellie-May’s notes or the reason for the appointment.

When asked about the “10 minute rule”, Dr Rowe said: “If you have 25 patients to see in a morning or afternoon and a lot of people are 15 minutes late or 20 minutes late you are never going to be able to manage your work.”